Technical feasibility of laparoscopic extended surgery beyond total mesorectal excision for primary or recurrent rectal cancer

Abstract

Relatively little is known about the oncologic safety of laparoscopic surgery for advanced rectal cancer. Recently, large randomized clinical trials showed that laparoscopic surgery was not inferior to open surgery, as evidenced by survival and local control rates. However, patients with T4 tumors were excluded from these trials. Technological advances in the instrumentation and techniques used by laparoscopic surgery have increased the use of laparoscopic surgery for advanced rectal cancer. High-definition, illuminated, and magnified images obtained by laparoscopy may enable more precise laparoscopic surgery than open techniques, even during extended surgery for T4 or locally recurrent rectal cancer. To date, the quality of evidence regarding the usefulness of laparoscopy for extended surgery beyond total mesorectal excision has been low because most studies have been uncontrolled series, with small sample sizes, and long-term data are lacking. Nevertheless, laparoscopic extended surgery for rectal cancer, when performed by specialized laparoscopic colorectal surgeons, has been reported safe in selected patients, with significant advantages, including a clear visual field and less blood loss. This review summarizes current knowledge on laparoscopic extended surgery beyond total mesorectal excision for primary or locally recurrent rectal cancer.

Keywords: Extended surgery; Laparoscopic surgery; Lateral pelvic lymph node dissection; Pelvic exenteration; Rectal cancer; Total mesorectal excision.

Figure 1

T2-weighted axial image of lateral pelvic lymph nodes. A 71-year-old male experienced lateral pelvic lymph nodes (LPLN) swelling in the left internal iliac region before chemoradiotherapy (CRT). The LPLN responded to CRT, but the patient underwent laparoscopic total mesorectal excision with left LPLN dissection. Pathologic examination of LPLNs showed two left internal iliac lymph node metastases.

Figure 2

Surgical view after laparoscopic left lateral pelvic lymph node dissection preserving the superior and inferior vesical arteries. The most frequent metastatic site of lateral pelvic lymph nodes was deep and around the inferior vesical vessels.

Figure 3

Surgical view after laparoscopic left lateral pelvic lymph node dissection with en bloc resection of the internal iliac artery. A: Distant view; B: Close-up view.

Figure 4

Surgical view after exposure of the dorsal vein complex. This patient underwent laparoscopic total pelvic exenteration for locally recurrent rectal cancer.